Provider Demographics
NPI:1558836650
Name:MAHN, REBECCA RAE (PA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:RAE
Last Name:MAHN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:RAE
Other - Last Name:SHINELDECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6250 HEIGHTS RAVENNA RD
Mailing Address - Street 2:
Mailing Address - City:FRUITPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49415-8697
Mailing Address - Country:US
Mailing Address - Phone:231-742-1983
Mailing Address - Fax:
Practice Address - Street 1:1700 CLINTON ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5502
Practice Address - Country:US
Practice Address - Phone:231-728-4601
Practice Address - Fax:231-728-5777
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008867363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant